Elongated connecting elements for minimally invasive surgical procedures

ABSTRACT

Apparatus and methods include an elongate connecting element including a body extending along a longitudinal axis between a first end and an opposite second end. The connecting element includes a first end portion at its first end and a second end portion at its second end. The connecting element includes a length between the first and second ends sized to extend between and be engaged to first and second anchors engageable to bony portions of the spinal column. The first and second end portions are positioned on opposite sides of the first and second anchors and project outwardly from the body of the connecting element to capture the first and second anchors between the first and second end portions.

BACKGROUND

The invention relates generally to medical devices and procedures. More particularly, the invention relates to devices and methods for spinal stabilization.

Stabilization of one or more levels of the spine is often accomplished with placement of an elongated connecting element, such as a rod construct, between bone anchors engaged to the vertebrae of the one or more levels. These procedures may employ various techniques and approaches for positioning the rod into the patient for engagement to the bone anchors. Depending on the technique and surgical instruments that are employed, differing types of rods may be selected for insertion into the patient. For example, rods that are implanted in percutaneous minimally invasive procedures where the rod is guided through skin and tissue to the anchors may employ a configuration that is not optimal for implantation in an open or mini-open surgical procedure in which the rod is positioned minimally invasively or invasively into the patient along a retracted tissue pathway. Furthermore, differing types of rods may be required in order function properly with differing types of insertion instruments or insertion techniques. Therefore, multiple types of rods are required to be available depending on the type of surgical procedure to be employed.

Thus, a need exists for improved elongated connecting elements and procedures for insertion and securement of elongated connecting elements at locations within a patient's body that can be employed in different types of surgical approaches and insertion instruments.

SUMMARY

Apparatus, methods, systems, procedures and implants for stabilization of one or more levels of the spine are described herein. The systems include an elongate connecting element including a body extending along a longitudinal axis between a first end and an opposite second end. The connecting element includes a first end portion at its first end and a second end portion at its second end. The connecting element includes a length between the first and second ends sized to extend between and be engaged to first and second anchors engageable to bony portions of the spinal column. The first and second end portions are positioned on opposite sides of the first and second anchors and project outwardly from the body of the connecting element to capture the first and second anchors between the first and second end portions. The apparatus, methods, systems, procedures and implants minimize invasiveness of the procedure into the patient. Applications in non-minimally invasive procedures are also contemplated.

According to one aspect, an implant system includes at least a first anchor engageable to a first vertebra and a second anchor engageable to a second vertebra. The system further includes an elongate connecting element extending along a longitudinal axis between a first end and an opposite second end with a length between the first and second ends sized to extend between and be engaged to the first and second anchors when the first and second anchors are engaged to the first and second vertebrae. The first and second vertebrae may be adjacent vertebrae, or include one or more vertebrae therebetween. The connecting element includes at least one end portion projecting outwardly from the body to contact at least one of the anchors to prevent the connecting element from passing through the anchor. In one embodiment, the anchor includes an elongated extension extending proximally from a bone engaging portion of the anchor, and the end portion of the connecting element contacts the extension to prevent the connecting element from passing through the extension. In another embodiment, the connecting element includes a second end portion at an opposite end thereof that contacts the other anchor and confines the first and second anchors between the end portions such that the connecting element cannot pass through either of the anchors while allowing the connecting element to be slidably adjusted along the extensions of the anchors.

According to another aspect, an implant system includes at least a first anchor engageable to a first vertebra and a second anchor engageable to a second vertebra. The implant system also includes an elongate connecting element having first and second end portions projecting outwardly therefrom. In a first orientation of the connecting element, the end portions are configured to pass through the first and second anchors. In a second orientation of the connecting element, the end portions contact opposite sides of the anchors to prevent the connecting element from passing through the anchors.

According to yet another aspect, a method comprises inserting into a patient an elongate connecting member between first and second anchors engaged to first and second vertebrae. In one embodiment, the connecting element includes end portions on opposite sides of the anchors that confine the anchors between the end portions as the connecting element is moved distally along the anchors to an implantation location. As used herein, “confine” or “confining” the anchors between the end portions means that the anchors or any portion thereof are located entirely or substantially entirely between the end portions and the end portions prevent the connecting element from passing through opposite side openings of the anchor. In another embodiment, the connecting element is inserted in an endwise manner through the anchors and then rotated from its insertion orientation so the end portions of the connecting element contact opposite sides of the anchors to confine the anchors between the end portions such that the connecting element cannot pass though the anchors when moved in an endwise manner. As used herein, movement or prevention of movement of the connecting element in an “endwise manner” or “endwise approach” means moving the connecting element in a direction defined by the longitudinal axis of the connecting element.

These and other aspects are also discussed below.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of one embodiment elongate connecting element.

FIG. 2 a perspective view of the connecting element of FIG. 1 and a pair of anchors with extensions for receiving the connecting element from a proximal approach.

FIG. 3 is a perspective view of the connecting element and anchor assemblies of FIG. 2 with the connecting element positioned in the anchor assemblies.

FIG. 4 a perspective view of the connecting element of FIG. 1 and a pair of anchor assemblies with extensions for receiving the connecting element from an endwise approach.

FIG. 5 is a perspective view of the connecting element and anchor assemblies of FIG. 4 with the connecting element positioned in the anchor assemblies from the endwise approach.

FIG. 6 is an elevational view of an inserter instrument and connecting element engaged thereto for positioning the connecting element to anchors engaged to a diagrammatically shown spinal motion segment.

FIG. 7 an elevational view of another embodiment inserter instrument and connecting element engaged there for positioning the connecting element to anchors engaged to a diagrammatically shown spinal motion segment.

FIG. 8 is a side elevation view of another embodiment connecting element.

FIG. 9 is a plan view of the connecting element of FIG. 8.

FIG. 10 is an end elevation view of the connecting element of FIG. 8.

DETAILED DESCRIPTION

For the purposes of promoting an understanding of the principles of the invention, reference will now be made to the embodiments illustrated in the drawings and specific language will be used to describe the same. It will nevertheless be understood that no limitation on the scope of the invention is intended. Any alterations and further modifications in the illustrated devices and described methods and further applications of the principles of the invention as disclosed herein are contemplated as would normally occur to one skilled in the art to which the invention relates.

Systems and methods include elongated connecting elements insertable into the body of a patient for stabilization along, for example, two or more vertebrae of a spinal column The connecting element can be positioned into the patient in minimally invasive surgical approaches where the connecting element is guided through skin and/or tissue of the patient to the implantation location. The connecting element can also be positioned into the patient in minimally invasive, mini-open and open surgical approaches where the skin and/or tissue is at least partially retracted along the insertion path of the connecting element. In one embodiment, the connecting element comprises a portion of a stabilization construct that includes at least two anchors engageable to respective ones of first and second vertebrae and the elongated connecting element is positioned between and engaged to the at least two anchors.

In one embodiment, the connecting element is positioned in a first orientation so that the connecting element can be guided through the anchors in an end-wise manner such that the leading end of the connecting element is initially introduced through a first anchor and then advanced toward and through a second anchor. The connecting element may be introduced directly into its implantation location on the anchors, or through extensions of the anchors that extend proximally from the implantation location through the skin of the patient. The connecting element is then rotated so that the anchors and/or first and second anchor extensions are confined between end portions that project outwardly from the ends of the connecting element. It is also contemplated that the connecting elements can be configured to extend between or be positioned between three or more anchors engaged to three or more vertebrae.

In a further embodiment, the connecting element is initially positioned in an orientation so that end portions of the connecting element capture first and second extensions of first and second anchors between the end portions. The connecting element is guided along the extensions to an implantation location on the anchors while maintaining the confined relationship with the anchors to prevent the connecting element from disengaging or passing through one or both of the extensions as it is moved distally to the implantation location. Other embodiments contemplate connecting elements that extend between or are positioned between three or more anchors engaged to three or more vertebrae.

In addition, a method includes inserting percutaneously or through a small incision at least first and second anchors and engaging the first and second anchors to respective ones of first and second bony portions. The method also includes guiding an elongated connecting element into the patient along a minimally invasive insertion path and between the anchors, and confining the anchor extensions and/or the anchors between outwardly projecting end portions of the connecting element during insertion of the connecting element or after the connecting element is located between the anchors.

In some embodiments, elongate extensions extend proximally from first and second anchors that are engaged to first and second bony portions of vertebrae. An inserter is mounted to a proximal end portion of at least one of the elongate extensions, and an elongate connecting element is guided to the first and second anchors by moving the inserter relative to the at least one extension. In other embodiments, the method includes guiding the elongate connecting element to a location between first and second anchors with an inserter that is not mounted to the anchor extensions. In either embodiment the connecting element is positioned in an insertion orientation so that an outwardly projecting end portion of the connecting element can pass through the extensions and/or anchors in an endwise manner. In either embodiment, the connecting element can be engaged to the anchors in its insertion orientation, or the connecting element can be rotated about its longitudinal axis to confine the anchors between outwardly projecting end portions of the connecting element before the connecting element is finally secured to the anchors.

In FIG. 1 there is shown an elongate connecting element 10 extending along a longitudinal axis 12 between a first end 14 and an opposite second end 16. Connecting element 10 includes a body 18 lying on longitudinal axis 12. In the illustrated embodiment, body 18 includes a circular cross-section orthogonal to longitudinal axis 12, although non-circular cross-sections are also contemplated. Connecting element 10 also includes a first end portion 20 at first end 14 and a second end portion 22 at said end 16. End portion 20 includes opposite flanges 23 a, 23 b that project outwardly adjacent to first end 14 to form first and second lips 24 a, 24 b. End portion 22 includes opposite flanges 25 a, 25 b that project outwardly from body 18 adjacent to second end 16 to form lips 26 a, 26 b. In the illustrated embodiment, lips 24 a, 24 b and lips 26 a, 26 b do not extend completely around body 18. Rather, lips 24 a, 24 b and lips 26 a, 26 b project outwardly only at diametrically opposite sides of body 18 so that end portions 20, 22 include an oval or oval-like cross-sectional shape orthogonal to longitudinal axis 12. End portions 20, 22 are aligned with one another so that lips 24 a, 26 a project outwardly from the same side of body 18, and lips 24 b, 26 b project outwardly from the same side of body 18 that is directly opposite the side of lips 24 a, 26 a. The intermediate sides 28, 30 (and their respective directly opposite sides not shown) of end portions 20, 22 include a substantially smaller lip, or do not include a flange or outwardly projecting lip but provide a smooth profile formed by an extension of the cross-section of body 18 along the intermediate sides 28, 30 of end portions 20, 22. Thus, end portions 20, 22 each have a cross-section dimension at sides 28, 30 that is less than the cross-sectional dimension defined by lips 24, 26. End portions 20, 22 also each include a tapered end portion 32, 34 extending to the respective end 14, 16. End portions 20, 22 further each include at least one recess or notch 36 a, 38 a in at least one side thereof for engagement to an inserter instrument, as discussed below. It is contemplated that a pair of identical notches 36 a, 36 b can be provided in the opposite sides of end member 20 and also in end member 22 (only notch 38 a shown).

Referring now to FIG. 2, there is shown a stabilization system 45 that includes a first anchor 50 and a second anchor 60 spaced from one another. In the illustrated embodiment, anchors 50, 60 each include a bone engaging portion 52, 62 and an extender 54, 64 coupled to the bone engaging portion. Extenders 54, 64 each include a receiving portion 56, 66 adjacent to the respective bone engaging portion that defines a support surface to receive connecting element 10 in its implantation location. Extenders 54, 64 also include removable extension portions 58 a, 58 b and 68 a, 68 b, respectively, extending from the corresponding receiving portion 56, 66. Extension portions 58 a, 58 b and 68 a, 68 b are sized to extend proximally from the bone engaging portion to a location outside the patient to provide a path to receiving portion 56, 66 in the patient. Further details of one example of suitable anchors with removable extension portions are provided in U.S. Patent App. Pub. No. 2007/0191840 published on Aug. 16, 2007, which is incorporated herein by reference in its entirety. Other embodiments contemplate an suitable anchor and extender extending from the anchor for use in system 45, including anchors that do not include removable extension portions.

Connecting element 10 is shown in FIG. 2 located outside the proximal ends of extenders 54, 64 and positioned with end portions 20, 22 oriented laterally, as indicated by arrowed line 70. Connecting element 10 is then positioned in this orientation through the proximal end openings of extenders 54, 64 so that extenders 54, 64 are confined between end portions 20, 22. The outwardly projecting end portions 20, 22 are sized so that they cannot pass through the spaces 55, 65 defined between break-off portions 58 a, 58 b of extender 54 and break-off portions 68 a, 68 b of extender 64 in the insertion orientation. End portions 20, 22 prevent connecting element 10 from slipping out of extenders 54, 64 as it is guided along extenders 54, 64 in a distal direction toward receiving portions 56, 66, as indicated by the down arrow of arrowed line 72. In addition, it is contemplated that end portions 20, 22 are sized to project outwardly from receiving portions 56, 66 of anchors 50, 60 to prevent connecting element 10 slipping out of anchors 50, 60 when implanted to the position shown in FIG. 3. Once connecting element 10 is positioned in receiving portions 56, 66, connecting element 10 can be maintained in its insertion orientation, or rotated a quarter turn about longitudinal axis 12 as shown by connecting element 10′ in FIG. 3. In either orientation, connecting element 10, 10′ can be secured in receiving portions 56, 66 with an engaging member, such as a set screw, cap nut or other suitable member engageable to anchors 50, 60.

Connecting element 10 can also be guided in an end-wise orientation or manner through extenders 54, 64 and/or receiving portions 56, 66. Connecting element 10′ is shown in FIG. 4 located outside the receiving portion 56 of anchor 50. In this orientation, end portions 20, 22 extend in the distal and proximal directions as indicated by arrowed line 72. Connecting element 10′ is then advanced in this orientation to pass end portion 22 through space 55 of anchor 50 and space 65 of anchor 60, as indicated by arrow 74 and as shown in FIG. 5. End portion 20 does not pass into and remains outside of anchor 50. Connecting element 10′ can then be secured to anchors 50, 60 in this insertion orientation, or rotated a quarter turn about longitudinal axis 12 as shown in FIG. 5 and to confine receiving portions 56, 66 between end portions 20, 22 and secured to anchors 50, 60 in the rotated orientation, as shown by connecting element 10 in FIG. 5. In other embodiments, connecting element 10′ can be positioned through spaces 55, 65 along extensions 54, 64 and then reduced distally into receiving portions 56, 66 to the implantation location.

FIGS. 6-7 show other embodiments insertion technique and instrumentation for implanting the connecting element 10. In FIGS. 6-7, vertebrae 90, 92 are shown diagrammatically and positioned below skin level S with tissue of the patient between the vertebrae and skin S. It is contemplated that the spinal column segment is part of a patient in which spinal surgery is to be performed with the present invention. It is also contemplated that the spinal column segment may comprise a non-human or non-living animal substrate, such as may be present with a training model to teach methods employing the surgical instruments and implants discussed herein.

Anchors 130, 132 are engaged to vertebrae 90, 92. Anchors 130, 132 each include a bone engaging portion 134 and a receiving portion 136 mounted to bone engaging portion 134. In the illustrated embodiment, bone engaging portion 134 is a bone screw and receiving portion 136 is a saddle or U-shaped head pivotally mounted to the head of the bone screw. Bone engaging portions 134 are shown as bone screws, but can also include any suitable bone engagement structure, including hooks, staples, spikes, bolts, wires, or clamps, for example. Receiving portion 136 is movable to rotate around the head of the bone screw to align passages of the receiving portions 136 to receive connecting element 10, 10′ in either orientation depending on the insertion technique that is employed. The passages of receiving portions 136 open proximally to receive a set screw, cap or other engaging member to secure connecting element 10 in receiving portions 136. Other embodiments contemplate receiving portions with laterally opening or obliquely opening passages, or passages that are encircled by receiving portion 136. In any event, the receiving portions 136 open at the cephaladly and caudally oriented sides of receiving portions 136 to accept connecting element 10′ in an endwise manner from an insertion path P so that a leading end of connecting element 10′ passes through anchor 130 and then anchor 132 and an opposite trailing end of connecting element 10′ is located adjacent to anchor 130.

The insertion instrumentation includes anchor extensions 100, 102 extending proximally from respective ones of anchors 130, 132 through skin level S to proximal end portions 104, 106. Extensions 100, 102 include distal end portions 108, 110, respectively, removably engaged to the receiving portions of respective ones of anchors 130, 132. The insertion instrumentation further includes an inserter 120 mounted to proximal end portions 104, 106 of extensions 100, 102. Inserter 120 includes a mounting portion 122 movably mounted to extensions 100, 102, and an elongate arm 124 extending transversely from mounting portion 122 for movement along an arc A that parallels insertion path P. Connecting element 10′ is removably engageable to the distal end 126 of elongate arm 124 in an insertion orientation where end portions 20, 22 are oriented proximally and distally so that end portion 22 can pass through opposite side openings of anchors 130, 132 without interference. Connecting element 10′ is movable with inserter 120 along insertion path P through skin S and tissue of the patient from a location outside the patient toward anchors 130, 132 and then between anchors 130, 132 for engagement thereto. Additional features and embodiments of anchor extensions and inserters are provided in U.S. Pat. No. 6,530,929 issued Mar. 11, 2003; U.S. Pat. No. 7,188,626 issued Mar. 13, 2007; U.S. Patent App. Pub. No. 2005/0171540 published on Aug. 4, 2005; U.S. Patent App. Pub. No. 2007/0049931 published on Mar. 1, 2007; and U.S. Patent App. Pub. No. 2008/0319477 published on Dec. 5, 2008; each of which is incorporated herein by reference in its entirety.

FIG. 7 shows a second inserter 150 positioned through an incision in skin S to guide connecting element 10′ in an endwise manner through anchors 130, 132. Inserter 150 includes an arm 152 with a distal end 154 engaged to end portion 20 of connecting element 10′ and a proximal handle 156. Inserter 150 is employed to guide connecting element 10′ to anchors 130, 132 in a freehand technique. The surgeon can monitor insertion and positioning of fusion implant 50 using fluoroscopy or other suitable imaging system. Additional details and embodiments of second inserter 150 are disclosed in U.S. Pat. No. 7,520,879 issued Apr. 21, 2009, which is incorporated herein by reference in its entirety.

FIGS. 8-10 show another embodiment connecting element 200. Connecting element 200 extends along a longitudinal axis 202 between a first end 204 and an opposite second end 206. Connecting element 200 includes a body 208 lying on longitudinal axis 202. In the illustrated embodiment, body 208 includes a circular cross-section orthogonal to longitudinal axis 202, although non-circular cross-sections are also contemplated. Connecting element 200 also includes a first end portion 210 at first end 204 and a second end portion 212 at second end 206. End portions 210, 212 each include a flange 213, 215 projecting outwardly from body 208 to form lips 214, 216, respectively. In the illustrated embodiment, lips 214, 216 do not extend completely around body 208. Rather, lips 214, 216 project outwardly only at one side of body 208. End portions 210, 212 are aligned with one another so that lips 214, 216 project outwardly from the same side of body 18. The remaining sides of end portions 210, 212 do not include an outwardly projecting flange but provide a smooth profile forming a tapered extension of the cross-section of body 208. End portions 210, 212 further each include at least one recess or notch 226 a, 226 b and notches 228 a, 228 b, respectively, in at least one side thereof for engagement to an inserter instrument, as discussed above. In this embodiment, connecting element 200 can be inserted in an endwise manner through anchors in close contact with supporting surfaces of the anchors at the implantation location one the anchors without having to offset the connecting element proximally from the support surface to accommodate flanges located on the distal side of the connecting element 200, such as is present with connecting element 10 discussed above. In any event, connecting element 200 is insertable for engagement to any of the anchors discussed herein using any of the instruments, techniques, and procedures discussed herein.

It is contemplated that the connecting element can be comprised of a metal material, such as stainless steel, titanium, chrome-cobalt alloys. The connecting element may also be comprised of a polymer, such as, for example, polyetheretherketone (PEEK), polyetherketoneketone (PEKK), polymethylmethacrylate, polyurethane, silicone, silicone-polyurethane copolymers, epoxy, polycarbonate, polyketone, polyester, polyethylene, polyimide, polylactic acid, polypropylene, polystyrene, polysulfone, polyvinyl chloride, polyamide, poly(tetrafluoroethene), polyphthalamide, polybutylene and mixtures or combinations of thereof. In addition, the connecting element can be linear along its longitudinal axis, curved along its longitudinal axis so that its longitudinal axis and body define an arc having at least one radius, or comprise multiple curved and/or linear segments along its length. In addition, the connecting element can be rigid to completely prevent spinal motion when secured to the anchors, semi-rigid to allow at least limited position, or flexible to permit motion between predefined limits of extension and/or flexion.

Although various embodiments have been described as having particular features and/or combinations of components, other embodiments are possible having a combination of any features and/or components from any of embodiments as discussed above. As used in this specification, the singular forms “a,” “an” and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, the term “a member” is intended to mean a single member or a combination of members, “a material” is intended to mean one or more materials, or a combination thereof. Furthermore, the terms “proximal” and “distal” refer to the direction closer to and away from, respectively, an operator (e.g., surgeon, physician, nurse, technician, etc.) who would insert the medical implant and/or instruments into the patient. For example, the portion of a medical instrument first inserted inside the patient's body would be the distal portion, while the opposite portion of the medical device (e.g., the portion of the medical device closest to the operator) would be the proximal portion.

While the application has been illustrated and described in detail in the drawings and foregoing description, the same is to be considered as illustrative and not restrictive in character, it being understood that only the selected embodiments have been shown and described and that all changes, modifications and equivalents that come within the spirit of the invention as defined herein or by any of the following claims are desired to be protected. 

1-18. (canceled)
 19. A method, comprising: inserting an elongate connecting member between first and second anchors engageable to first and second vertebrae, wherein the connecting element includes end portions at opposite ends of the connecting element that are located on opposite sides of the anchors to confine the anchors between the end portions and prevent the connecting element from passing through the anchors in an endwise manner defined by a longitudinal axis of the connecting element while permitting the connecting element to move proximally and distally along the first and second anchors.
 20. The method of claim 19, wherein the connecting element is inserted in the endwise manner through the anchors in an insertion orientation and then rotated from the insertion orientation so the end portions of the connecting element contact opposite sides of the anchors to confine the anchors between the end portions.
 21. The method of claim 19, further comprising rotating the connecting element between an insertion orientation in which the end portions are positioned to pass through receiving portions of the anchors in the endwise manner and a second orientation in which the end portions engage the receiving portions to prevent the end portions from passing through the receiving portions in the endwise manner.
 22. The method of claim 19, wherein the connecting element comprises a body and the end portions each include opposite flanges that project outwardly from the body to form first and second lips.
 23. The method of claim 22, wherein the lips do not extend completely around the body.
 24. The method of claim 22, wherein the first lips each project outwardly from a first side of the body and the second lips each project outwardly from a second side of the body that is opposite the first side of the body.
 25. The method of claim 22, wherein the end portions each have an oval cross-sectional shape.
 26. The method of claim 19, wherein the anchors each comprise an extender that includes a receiving portion and an extension portion defining a longitudinal axis and the connecting element is inserted between the anchors by positioning the connecting element through proximal end openings of the extension portions such that the extenders are confined between the end portions and moving the connecting element along the axes defined by the extension portions in a distal direction until the connecting element is positioned in passages of the receiving portions.
 27. The method of claim 26, further comprising rotating the connecting element a quarter turn about the longitudinal axis of the connecting element to move the connecting element between an insertion orientation in which the end portions are positioned to pass through the receiving portions in the endwise manner and a second orientation in which the end portions engage the receiving portions to prevent the end portions from passing through the receiving portions in the endwise manner
 28. The method of claim 26, wherein the extension portions are removable from the receiving portions.
 29. A method, comprising: inserting first and second anchors into first and second vertebrae; and inserting an elongate connecting member between the anchors in an endwise manner defined by a longitudinal axis of the connecting member such that a body of the connecting element is disposed in receiving portions of the anchors and the anchors are positioned between end portions at opposite ends of the connecting element.
 30. The method of claim 29, wherein the connecting element is inserted between the anchors in an insertion orientation such that the end portions are positioned to move in the endwise manner through the receiving portions and the method further comprises rotating the connecting element from the insertion orientation to a second orientation such that the end portions contact opposite sides of the anchors to confine the anchors between the end portions.
 31. The method of claim 30, wherein the anchors each include a bone penetrating portion that is rotatable relative to a respective one of the receiving portions, and the method further comprises rotating at least one of the receiving portions relative to at least one of the bone penetrating portions to align passages of the receiving portions to receive the connecting element.
 32. The method of claim 30, further comprising engaging anchor extensions of an insertion instrument with the anchors and pivoting an elongate arm of the insertion instrument relative to the anchor extensions with the connecting element fixed to the elongate arm to insert the connecting element into passages of the receiving portions.
 33. The method of claim 30, wherein the end portions each include opposite flanges that project outwardly from the body to form first and second lips, wherein the lips do not extend completely around the body, and wherein the first lips each project outwardly from a first side of the body and the second lips each project outwardly from a second side of the body that is opposite the first side of the body.
 34. A method, comprising: inserting first and second anchors into first and second vertebrae; and inserting an elongate connecting member between the anchors such that a body of the connecting element is disposed in receiving portions of the anchors and the anchors are positioned between end portions at opposite ends of the connecting element, wherein the anchors each comprise an extender that includes one of the receiving portions and defines a longitudinal axis and the connecting element is inserted into the receiving portions by positioning the connecting element through proximal end openings of the extenders and moving the connecting element along the axes in a distal direction until the connecting element is positioned in passages in the receiving portions and the extenders are confined between the end portions.
 35. The method of claim 34, further comprising rotating the connecting element a quarter turn about a longitudinal axis defined by the connecting element to move the connecting element from an insertion orientation to a second orientation, wherein the connecting element is positioned to move through the receiving portions in the endwise manner when in the insertion orientation and is prevented from moving through the receiving portions in the endwise manner when in the second orientation.
 36. The method of claim 34, wherein the end portions each have a maximum width that is greater than that of the passages.
 37. The method of claim 34, further comprising engaging anchor extensions of an insertion instrument with the anchors and pivoting an elongate arm of the insertion instrument relative to the anchor extensions with the connecting element fixed to the elongate arm to insert the connecting element into the passages.
 38. The method of claim 34, further comprising engaging the connecting element with a distal end of an arm of an insertion instrument, the arm of the insertion instrument being fixed to a proximal handle of the insertion instrument such that inserting the connecting element between the anchors comprises guiding the connecting element to the anchors using a freehand technique. 